MEDICARE: WISCONSIN NEUROLOGY CLINIC, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	38580	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639101405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN NEUROLOGY CLINIC, LLC

Provider Business Mailing Address
First Line	:	2603 W RAWSON AVE
Second Line	:	SUITE 128
City	:	OAK CREEK
State	:	WI
Zip	:	53154-8422
Country	:	US
Telephone Number	:	414-431-6760
Fax Number	:	414-431-6761

Provider Business Practice Location Address
First Line	:	2603 W RAWSON AVE
Second Line	:	SUITE 128
City	:	OAK CREEK
State	:	WI
Zip	:	53154-8422
Country	:	US
Telephone Number	:	414-431-6760
Fax Number	:	414-431-6761

Authorized Official
Title or Position	:	OWNER
Name	:	VIRENDRA K MISRA
Credential	:	MD
Telephone Number	:	414-431-6760

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	10/24/2007

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